Surgical instruments for positioning suture knots

ABSTRACT

A knot positioning implement that includes an elongated tube that has an interior and first and second opposite ends that each have an opening therein. The first end of the elongated tube is forked and the second end includes a threaded connector. The implement further includes a fiberoptic core that includes at least one fiberoptic strand extending through the interior of the elongated tube. Light is transmitted through the opening in the first end of the elongated tube when the at least one fiberoptic strand is energized.

FIELD OF THE INVENTION

The present invention relates generally to methods and devices forplastic surgery and, more particularly, to a necklift procedure that isminimally invasive and to instruments for performing the procedure.

BACKGROUND OF THE INVENTION

Conventional neck rejuvenation surgeons advocate procedures that alterthe anatomy of the neck to restore a more youthful neck contour. Theseinvolve platysmal manipulation such as muscle advancement and/ordivision, and frequently sub-platysmal fat excision. Partial resectionof submandibular gland tissue may be performed as well. These techniquesvary in complexity and may result in significant complications,including post-operative bleeding, nerve injury, permanent visible skindeformities caused by muscle division, or over-resection of fat.

Plastic and reconstructive surgeons have long sought to develop methodsand devices to aid in the support of physical structures that have losttheir natural tension and support. The most often treated areas includethe face, the chest region, the buttocks and other regions that losetension and sag. Current devices are not always adequate in providing anatural-looking structure to prevent such loss of tension in thesestructures.

The aging process causes gradual and predictable changes in the softtissue layers of the lower face and neck, the anatomical basis of whichhas been well documented. Loss of elasticity and fragmentation ofcollagen results in rhytid formation and skin redundancy. Subcutaneousfat thickens and droops or is ptotic and becomes more noticeable.Stretching of the fascia and musculature results in a loss of thesupporting ‘sling’ of the submentum, often resulting in submandibulargland ptosis. Further loss of tone and muscular atrophy results inbanding of the medial platysmal borders, blunting of the cervicomentalangle and loss of lateral mandibular definition.

The classical necklift's failure in adequately addressing theconsequences of aging in the neck has prompted the development of anumber of modifications and adjunctive procedures. These include skinexcisions, various lipoplasty techniques, anterior or posteriorly basedplatysmal transection, resection, or plication procedures, SMAS-platysmaflaps, and even suture suspension techniques. However, thesemodifications have their limitations.

Problems with scar contractures and hypertrophic scarring have resultedin the near abandonment of midline skin excision with subsequent Z, W orT-plasty. Liposuction or direct lipocontouring plays an important rolein the aging neck.

SUMMARY OF THE PREFERRED EMBODIMENTS

In accordance with a first aspect of the present invention, there isprovided a knot positioning implement that includes an elongated tubethat has an interior and first and second opposite ends that each havean opening therein. The first end of the elongated tube is forked andthe second end includes a threaded connector. The implement furtherincludes a fiberoptic core that includes at least one fiberoptic strandextending through the interior of the elongated tube. Light istransmitted through the opening in the first end of the elongated tubewhen the at least one fiberoptic strand is energized.

In accordance with another aspect of the present invention, there isprovided a method of positioning a suture knot under the skin of aperson. The method includes providing a knot positioning implement thatincludes an elongated tube having an interior and first and secondopposite ends each having an opening therein. The first end of theelongated tube is forked, which defines a recess therein, and the secondend includes a threaded connector. The method also includes the steps ofpulling two ends of a suture through an opening in the skin, tying thetwo ends of the suture into a knot, placing the knot into the recess inthe forked end of the knot positioning implement, and pushing the knotthrough the opening in the skin using the knot positioning implement.

In a preferred embodiment, the knot positioning implement includes afiberoptic core extending through the interior of the elongated tube,whereby light is transmitted through the opening in the first end of theelongated tube when the at least one fiberoptic strand is energized. Inanother preferred embodiment, the opening in the skin includes a skinport inserted therein through which the knot positioning implement andknot are inserted. In another preferred embodiment, the knot positioningimplement is connected to a handset before use.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention may be more readily understood by referring to theaccompanying drawings in which:

FIG. 1 is a perspective view of a tape template in accordance with apreferred embodiment of the present invention;

FIG. 2 is a view of the tape template of FIG. 1 being used to markpuncture locations on a patient's chin;

FIG. 3 is a front elevational view of a lancet in accordance with apreferred embodiment of the present invention;

FIG. 4 is a perspective view of the lancet of FIG. 3;

FIG. 5 is a view of the lancet of FIG. 3 being used to make a puncture;

FIG. 6 is a side elevational view of a handset in accordance with apreferred embodiment of the present invention;

FIG. 7 is a sectional side elevational view of the handset of FIG. 5showing the fiberoptic core;

FIG. 8 is a cross-sectional view of the handset of FIG. 5 before dockingwith a skin port in accordance with a preferred embodiment of thepresent invention;

FIG. 9 is a cross-sectional view showing the skin port inserted througha patient's skin before deployment;

FIG. 10 is a cross-sectional view showing the skin port inserted througha patient's skin after deployment;

FIG. 11 is a perspective view of the skin port;

FIG. 12 is a cross-sectional view of another embodiment of a skin port;

FIG. 13 is a side elevational view of a threading device in accordancewith a preferred embodiment of the present invention;

FIG. 14 is a sectional side elevational view of the threading device ofFIG. 13;

FIG. 15 is a view of the threading device of FIG. 13 being used on apatient;

FIG. 16 is another view of the threading device of FIG. 13 being used ona patient;

FIG. 17 illustrates the threading device of FIG. 13 passing through thesubcutaneous facial ligaments and neurovascular structures.

FIG. 18 is a side elevational view of a knot positioning implement inaccordance with a preferred embodiment of the present invention;

FIG. 19 is a view of a patient with a threaded skin port placed in themidline sub-mental access site and a suture knot extending therethrough;

FIG. 20 is a cross-sectional view of the knot positioning implement ofFIG. 15 pushing the knot through the threaded skin port and under apatient's skin;

FIG. 21 is a side elevational view of a threaded skin port in accordancewith a preferred embodiment of the present invention;

FIG. 22 is a sectional side elevational view of the threaded skin portof FIG. 21;

FIG. 23 is a perspective view of the threaded skin port of FIG. 21;

FIG. 24 is a side elevational view of a fiberoptic suture in accordancewith a preferred embodiment of the present invention; and

FIG. 25 is a view of a patient with the support matrix shown in hiddenlines.

Like numerals refer to like parts throughout the several views of thedrawings.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

Described herein are preferred embodiments of a technique for plasticsurgery (e.g., liposuction to a person's chin or jaw area) that onlyuses one small incision. The technique involves several steps which eachrequire specific instrumentation. The technique is referred to herein asPercutaneous Trampoline Platysmaplasty.

The liposuction portion of the procedure is performed without a largeincision under the chin. The placement of the suture support matrix isperformed through several small access sites in the neck area under thejaw. The advantage is that the entire support system can be placedwithout the typical large incision under the chin that is necessary forthe surgeons to see the operative field. In addition the surgery is lessinvasive and does not require an extensive dissection of the skin in thearea under the chin.

The accurate placement of the support suture (also referred to herein asthe support structure or support matrix 200 and is shown in FIG. 25)will be described herein along with the description of each of theindividual instruments or devices that may be used in connection withsuch procedure.

As described above, the inventive aspects of the present inventioninvolve the placement of the support matrix 200 and not the actualliposuction technique. Therefore, it will be understood that anyreferences to liposuction techniques herein are only exemplary.

It will be appreciated that terms such as “front,” “back,” “top,”“bottom,” “side,” “upwardly” and “downwardly” used herein are merely forease of description and refer to the orientation of the components asshown in the figures. It should be understood that any orientation ofthe instruments and articles and the components thereof described hereinis within the scope of the present invention.

Referring to FIGS. 1-2, template tape (or tape members) 10 will bedescribed. In a preferred embodiment, tape 10 is a clear piece of tapewith perforations 12 therethrough that are spaced apart at predeterminedlocations. Tape 10 includes adhesive thereon so that it can be securedto the patient's skin. In an exemplary embodiment, tape 10 is a one inchwide clear tape with about 2 mm circular perforations 12 definedtherethrough that are spaced about every 5 mm along the center of thetape. The perforations 12 are preferably positioned along thelongitudinal center of the tape 10, however this is not a limitation onthe present invention. In another embodiment, tape 10 is not clear. In apreferred embodiment, tape 10 is provided in roll form. However, this isnot a limitation on the present invention.

Tape 10 is used in immediate pre-operative planning to determine theplacement of access sites 14, which will determine the placement of thesupport matrix 200. Tape 10 is used as a guide to help provide properplacement of each suture and its corresponding pivot point (as describedbelow). Perforations 12 are used to mark access sites 14 for thesurgery.

In a preferred embodiment, first and second tape members 10 are placedon each side of the skin overlying the undersurface of the mandible, asis shown in FIG. 2. Preferably, tape 10 is utilized with the patientsitting upright, which allows the natural neck contours to be visible.This is not a limitation on the present invention, however. The surgeonuses tape 10 and the plurality of perforations 12 to develop a surgicalapproach that is individually tailored for each patient, depending onthe correction desired. As those skilled in the art will appreciate,placement of the support matrix 200 will be different for differentpatients depending on the patient's anatomy.

The exemplary 5 mm span between perforations 12 allows placement ofpivot points in close proximity. This results in a dense support matrixallowing elevation of muscle and glandular tissue. For example, pivotpoints may be placed 1-2 cm apart if minimal support is needed. Thoseskilled in the art will be able to make determinations as to where theaccess sites 14 should be located based on the patient's needs. Forexample, as is shown in FIG. 2, the surgeon has only chosen four accesssites 14 on each side.

As shown in FIG. 2, after the tape 10 has been placed and the surgeonhas determined the structure of the support matrix 200, the surgeonmarks skin exposed through the desired perforations 12 with a surgicalmarking pen or the like. These markings 14 indicate the areas thatrequire suture placement to elevate the soft tissue of the neck. In apreferred embodiment, as is shown in FIGS. 2 and 5, the markings 14 madeusing the first tape member 10 are symmetrical to the markings 14 madeusing the second tape member 10.

As will be described below, each of the markings 14 define a location oraccess site that will be punctured to allow subcutaneous access at thatlocation. For simplicity, because each access site is marked and thenpunctured, the access sites, markings and punctures will all be labeled14 herein.

As will be appreciated by those skilled in the art, in areas wheresignificant platysmal banding or glandular ptosis is evident significantsupport will be required. To achieve this, multiple suture strands willbe required. As each area to be elevated is recognized, a correspondingtape perforation 12 is marked 14 to insure that suture placement isaccurate.

It will be understood that tape 10 is preferably used before performingliposuction. However, this is not a limitation on the present invention.In another embodiment, tape 10 can be used after liposuction isperformed. In another embodiment, the tape 10 can be omitted and thesurgeon can mark or puncture the skin as desired.

It will appreciated by those skilled in the art that the tape 10 can beused on areas of the body other than the chin. For example, the tape(and the remainder of the procedure described below) can be used for acheek lift.

After the desired markings 14 have been made, the patient is ready forliposuction. The patients head and neck are prepped and draped in asterile fashion and local anesthetic is injected into the area under thechin. A small opening (referred to herein as the midline sub-mentalaccess site) is made in this area. Tumescent fluid is injected into theentire area under the chin, including the neck region. Liposuction isperformed on the entire region. Upon completion, the area is once againinfiltrated with the tumescent fluid. This subcutaneous infusion resultsin the elevation of the skin from the platysma muscle.

With reference to FIGS. 3-5, after completion of liposuction, thepatient is ready for placement of the support matrix 200. A lancet 40 isused to create access sites 14 by puncturing the dermis at the pointsmarked using tape 10.

As shown in FIG. 3, lancet 40 includes a blade 42 that has two sharpedges 43 that end at a point 44 with two blunt edges 46 therebelow. In apreferred embodiment, blade 42 is about 8 mm in length. Blunt edges 46of blade 42 extend from a flange or stop member 48 that prevents blade42 from going deeper into the skin than desired. Flange 48 ensuresconsistent depth of blade penetration. Also, blade 42 is sized to allowplacement of skin ports 80 as described below.

Stop member 48 has an upper surface 48 a and a lower surface 48 b. Theblade 42 extends upwardly from the upper surface 48 a of the stop member48. As is shown in FIG. 3, the two sharp edges 43 each have first andsecond ends 43 a and 43 b, respectively and the two blunt edges 46 eachhave first and second ends 46 a and 46 b, respectively.

In a preferred embodiment, the first ends 43 a of the sharp edges 43meet at point 44 and extend downwardly from point 44 at an angle of 90°or less. The first ends 46 a of the two blunt edges 46 extend downwardlyfrom the second ends 43 b of the two sharp edges 43. The sharp edges 43and blunt edges 46 meet at an obtuse angle. The second ends 46 b of thetwo blunt edges 46 are connected to the stop member 48, which, in apreferred embodiment, is disc-shaped. However, this is not a limitationon the present invention. In an alternative embodiment, the blade 42 canextend from the stop member 48 at a non-right angle (e.g., an acuteangle).

In a preferred embodiment, lancet 40 includes an attachment member 50that extends downwardly from the lower surface 48 b of the stop member48 and allows the lancet 40 to be secured on a standard scalpel handle52. In another embodiment, lancet 40 can be provided with a unitaryhandle.

The subcutaneous infusion described above results in the elevation ofthe skin from the platysma muscle. Once infiltrated, the access sites 14are developed by puncturing of the skin with the percutaneous lancet 40at the markings developed using tape 10, as shown in FIG. 5. Lancet 40allows puncturing of the skin in order to gain access to the neck regionand preferably ensures that each access site is as small as possible,allowing the placement of the support system 200.

It will be understood that in a preferred embodiment, lancet 40 createspunctures instead of incisions, which minimalizes trauma and the risk ofscarring. However, incisions can be used in another embodiment.

Referring to FIGS. 6-7, the next instrument used in the procedure is ahandset or handle 60. Handset 60 is embodied in a reusable insertiondevice with an instrument dock 64 at an end thereof. In a preferredembodiment, handset 60 also includes a fiber-optic light port 62. In apreferred embodiment, the handset is ergonomically designed to fit intothe surgeon's hand when gripped. However, this is not a limitation onthe present invention. Preferably, handset 60 is made of a metal, suchas stainless steel or titanium. However, it can be made of othermaterials, such as a plastic or the like. As is described below,instrument port 64 is compatible with a number of the instruments thatare used in the inventive surgical procedure. The design structure andform allows right to left hand interchangability with ease andprecision.

In a preferred embodiment, instrument dock 64 includes an inner threadedsurface or threaded female connector 66 and a larger male connector 68that interlocks with the skin ports 80 (described below) allowingdeployment and illumination. The instrument dock 64 is adapted to dockwith certain instruments, as will be described more fully below. Handset60 will be described more fully below in conjunction with theinstruments with which it is intended to be used.

The fiberoptic light port 62 allows docking with a fiberoptic light cord(not shown). The transmission of fiberoptic light through the handset 60illuminates each device when it is attached to the working end orinstrument dock 64.

In a preferred embodiment, the handset 60 includes a fiberoptic core 70,which is made up of at least one, and preferably a plurality, offiberoptic strands. When a fiberoptic light cord is connected to lightport 62, the light is transmitted through the fibers and out through anopening 72 that is coaxial with female connector 66.

In another embodiment other types of lighting can be used. For example,LED, incandescent, fluorescent and other light sources can be used.However, it will be understood that the light transmission is not alimitation on the invention. The handset 60 (and associated instruments)can be provided without a fiberoptic core.

FIGS. 8-11 show a skin port 80. In a typical procedure, a plurality ofskin ports 80 are used. In a preferred embodiment, skin ports 80 aredisposable clear plastic sleeves that are each inserted into one of theaccess sites 14 created by lancet 40.

Generally, skin port 80 includes a flange or cuff 82 that has a tube 84that extends from it. One end of the tube or sleeve 84 is inserted intothe puncture 14 in the skin until the flange 82 rests against the outersurface of the skin. The flange 82 and tube 84 cooperate to define atunnel 86 that will provide access to the area under the skin.Preferably, the port 80 is comprised of colored clear plastic. However,the port 80 can also be made of other materials, does not have to beclear and does not have to be colored.

In a preferred embodiment, the handset 60 is used to deploy each port 80through the individual access sites 14. Preferably, the skin ports 80come in a kit, however this is not a limitation on the presentinvention. The handset 60 design allows quick interlocking with the skinport 80 to remove it from the kit. It will be understood that any designthat allows the handset 60 to interlock with or engage the skin port 80so that it can be deployed into the access site 14 is within the scopeof the present invention.

In a preferred embodiment, the port 80 is snap fit onto the maleconnector 68. For example, as shown in FIG. 8, the male connector 68 caninclude a ridge 68 a extending circumferentially therearound thatcooperates with an indented ring 82 a in the flange 82. The ridge 68 aand indented ring 82 a provide a snap fit so that the port 80 is engagedwith the male connector 68 of the handset 60. Other snap fitarrangements are contemplated.

The tube 84 is then inserted through the access site 14. As shown inFIGS. 8-11, in a preferred embodiment, the skin port 80 includes ananchor system that comprises threads 88 on the outer surface of the tube84 and a folding mechanism 90. The folding mechanism 90 preferablyincludes a pair of folding members 90 a that are attached to aninternally threaded ring 90 b that moves up and down the tube 84 onthreads 88.

As is shown in FIG. 8, the male connector 68 includes a plurality ofteeth 68 b on an end thereof that are adapted to interlock with teeth 82b on the port 80. When the port 80 is engaged with the instrument dock64, teeth 68 b engage or mesh with teeth 82 b. After the tube 84 hasbeen inserted through the access site 14, to deploy the foldingmechanism 90, the handset 60 is turned in a clockwise direction (port 80can be designed to deploy in a counter-clockwise direction as well).Because teeth 68 b and 82 b are engaged, the tube 84 turns with handset60 and within flange 82, thereby causing the internally threaded ring 90b to move upwardly along threads 88. As can be seen in FIG. 11, foldingmembers 90 a include a fold crease 90 c. As threaded ring 90 b movesupwardly, the folding members 90 a fold, as shown in FIG. 10, therebyproviding an anchor and preventing port 80 from pulling out of accesssite 14. The folding members 90 a can be disposed in an unfoldedposition (FIG. 9) and a folded position (FIG. 10).

In a preferred embodiment, flange 82 includes a plurality of spikes 94extending downwardly therefrom that burrow into the skin and help anchorthe port 80 in place.

During placement of the port 80, because the handset 60 includes thefiber optic core 70 and the skin port 80 is clear, upon insertion,transcutaneous visualization of the lighted probe tip will allow safedeployment of skin port 80. Because of the anchoring system, as thehandset is withdrawn, the ridge 68 a pulls out of the indented ring 82 aand the skin port 80 is secured in place. In another embodiment, thesurgeon can use his/her thumb to aid in separating the port 80 from theinstrument dock 64.

Preferably, the ports 80 are disposable and are only used for a singlesurgery. It will be understood that the ports are simply used to gainaccess to the surgical field. Therefore, the type of port used is not alimitation on the present invention. Any type of port that providesaccess through the skin is within the scope of the present invention.The transillumination of light gives three dimensional feedback to thesurgeon.

As shown in FIG. 12, in an alternative embodiment, port 96 can have atube 84 that is oriented at a non-right angle with respect to the flange82. For example, tube 84 can be oriented at a 45 degree angle withrespect to the flange.

FIGS. 13-17 show a threading device 100. In a preferred embodiment,threading device 100 is a stainless steel malleable rod or tube thatincludes an eyelet 102 defined therein and a rounded, blunt tip 104.Preferably, threading device 100 also includes a fiberoptic core 106allowing illumination of tip 104. In this embodiment, the tip 104 ispreferably made of a translucent material, such as a plastic that isaffixed to the main body of the threading device 100. Threading device100 includes an end 108 that is designed to dock with instrument dock 64of handset 60. In a preferred embodiment, end 108 is threaded forengagement with female connector 66, however, it will be appreciatedthat end 108 can dock with instrument dock 64 in a number of differentways. For example, instrument dock 64 can include a set screw that holdsthreading device 100 in place or some type of snap or press fit can beprovided. In another embodiment, a clamp or chuck, similar to that on adrill can be used. Also, end 108 can be internally threaded and can dockwith an externally threaded instrument dock. Instrument dock 64 allowsquick connection and disconnection with threading device 100.

In an embodiment where handset 60 includes a fiber-optic light port 62,docking of end 108 (which includes an opening 108 a therein) withinstrument dock 64 allows the transmission of light to tip 104 ofthreading device 100. In another embodiment other types of lighting canbe used. For example, LED, incandescent, fluorescent and other lightsources can be used.

It will be understood that, eyelet 102 is used to secure the suture 150.Eyelet 102 can be located anywhere along threading device 100.

In use, threading device 100 (and suture 150) are inserted through thevarious skin ports 80 and the support matrix 200 is weaved and created.

An exemplary construction of a support matrix 200 will now be described.For example, as shown in FIG. 15, after first end 150 a of the suture150 is connected to eyelet 102, the handset 60 is grasped by the surgeonand the threading device is inserted through a first skin port 80 a. Thelighted tip 104 of threading device 100 illuminates the work area andtransilluminates through the skin allowing the surgeon to determine theproper placement of the support matrix 200 and the location of the tip104. As described above, in a preferred embodiment, port 80 is clear foraiding in the passage of the threading device 100. In other words, whenthe tip 104 of threading device 100 gets close to port 80 it willtransilluminate.

The threading device 100 is preferably long enough that it can bethreaded from one side of the jaw line to the other such that the tip104 is brought out through a second skin port 80 b on the opposite sideof the jaw from which it was inserted. At this point, the tip 104 isgrasped by the surgeon and the suture 150 is pulled through the areaunder the neck. Then the threading device 100 is disconnected from thehandset 60 allowing the threading device 100 and the suture 150 to bepulled through the second skin port 80 b, as is shown in FIG. 16.

The threading device 100 is then turned and reconnected to the handset60 and is then reinserted through second skin port 80 b and is passedsubcutaneously to the contralateral side exiting through third skin port80 c. The threading device 100 is once again disconnected from thehandset 60 and is reconnected after the threading device and suture 150are pulled through third skin port 80 c.

Next, the threading device 100 is turned and reconnected to the handset60 and is then reinserted through third skin port 80 c and is passedsubcutaneously to the contralateral side exiting through fourth skinport 80 d. At this point, the threading device 100 is once againdisconnected from the handset 60 and is reconnected after the threadingdevice and suture 150 are pulled through fourth skin port 80 d.

The threading device 100 is then turned and reconnected to the handset60 and is then reinserted through fourth skin port 80 d and is passedsubcutaneously to the contralateral side exiting through fifth skin port80 e. At this point, the threading device 100 is once again disconnectedfrom the handset 60 and is reconnected after the threading device andsuture 150 are pulled through fifth skin port 80 e.

Next, the threading device 100 is turned and reconnected to the handset60 and is then reinserted through fifth skin port 80 e and is passedsubcutaneously to the midline sub-mental access site which preferablyincludes a threaded skin port 120 (described more fully hereinbelow).The threading device 100 and first end 150 a of suture 150 are pulledthrough the threaded skin port 122 and the threading device isdisconnected from the handset 60. The first end 150 a of suture 150 isthen cut from and/or untied from the threading device 100.

Now, the second end (or distal end) 150 b of suture 150, which isextending from first skin port 80 a is secured to the eyelet 102 of thethreading device 100 and the threading device 100 is connected to thehandset 60. The handset 60 is grasped by the surgeon and the threadingdevice is inserted through the first skin port 80 a and is passedsubcutaneously to the contralateral side exiting through sixth skin port80 f. At this point, the threading device 100 is once again disconnectedfrom the handset 60 and is reconnected after the threading device andsuture 150 are pulled through sixth skin port 80 f.

Next, the threading device 100 is turned and reconnected to the handset60 and is then reinserted through sixth skin port 80 f and is passedsubcutaneously to the contralateral side exiting through seventh skinport 80 g. At this point, the threading device 100 is once againdisconnected from the handset 60 and is reconnected after the threadingdevice and suture 150 are pulled through seventh skin port 80 g.

The threading device 100 is then turned and reconnected to the handset60 and is then reinserted through seventh skin port 80 f and is passedsubcutaneously to the contralateral side exiting through eighth skinport 80 h. At this point, the threading device 100 is once againdisconnected from the handset 60 and is reconnected after the threadingdevice and suture 150 are pulled through eighth skin port 80 h.

Next, the threading device 100 is turned and reconnected to the handset60 and is then reinserted through eighth skin port 80 h and is passedsubcutaneously to the threaded skin port 120 at the midline sub-mentalaccess site. The threading device 100 and second end 150 b of suture 150are pulled through the threaded skin port 120 and the threading deviceis disconnected from the handset 60.

As will be understood by those skilled in the art, the tube 84 on theskin ports 80 is long enough that when the threading device 100 isinserted therethrough the suture 150 will anchor itself by encirclingthe facial retaining ligaments during the procedure described above.Preferably, each time the threading device 100 and suture 150 are passedthrough a port 80, the suture is secured on the facial retainingligaments, thereby creating an anchor or pivot point.

It will be understood that the number of access sites 14, ports 80and/or passes, etc. described above are merely exemplary and any numbercan be used in the presently described procedure, as required by theparticular surgery.

Transcutaneous light transmission from the tip 104 of the threadingdevice 100 gives feedback allowing the surgeon to determine the locationof the tip 104 as the support matrix 200 is weaved and created. Thisfeedback allows the placement of each individual strand relative toareas of needed support. This allows placement of the suture strands 150adjacent to the muscle, deep to the skin and fat layers.

Preferably, in each port 80, the end of the tube 84 that is associatedwith the flange 82 has a beveled or tapered edge 84 a, which helpsprevent the tip 104 of the threading device 100 from catching inside thetunnel 86, during insertion.

In another embodiment, two threading devices 100 that are each connectedto an opposite end of the suture 150 can be used. In this embodiment thefirst threading device 100 does not have to be disconnected from the endof the suture 150 before the second end of the suture 150 is threadedthrough the skin. In yet another embodiment, the suture 150 can come ina kit with two disposable threading devices 100 attached to the oppositeends 150 a and 150 b. After forming the matrix 200, the threadingdevices 100 can be cut from the suture 150 and then the suture can betied.

FIGS. 19-23 show the threaded skin port 120 used for the midlinesub-mental access site. The threaded skin port 120 is inserted at thesame time as the skin ports 80 described above. However, this is not alimitation on the present invention. The port 120 includes a flange 122having a tube 124 extending therefrom. The tube 124 is preferablythreaded 126. As is shown in FIG. 22, the tube 124 and flange 122cooperate to define a tunnel 128 therethrough. In a preferredembodiment, the portion of the tunnel 128 in the flange 122 includes abeveled or tapered edge 128 a.

In a preferred embodiment, the port 120 includes a pair of handleportions 130 extending upwardly from the flange 122 that aid the surgeonin threading the port 120 into the midline sub-mental access site.However, the handle portions 130 are not a limitation on the presentinvention and can be omitted. It will be understood that any skin portthat allows access through the skin is within the scope of the presentinvention. For example, skin port 80 or something similar can be used atthe midline sub-mental access site. In another embodiment, port 120 canbe used at access site 14. In a preferred embodiment, port 120 is clearfor aiding in the passage of the threading device 100. In other words,when the tip 104 of threading device 100 gets close to the port 120 itwill transilluminate.

In use, the tube 124 is inserted into the midline sub-mental accesssite. The handle portions 130 are grasped and the port 120 is turned sothat the threads 126 are threaded into the skin until the bottom surfaceof the flange 122 rests against the outer surface of the skin.

In another embodiment, a port similar to skin port 80 described above,but somewhat modified can be used for mid-line access. In thisembodiment, the flange includes a threaded interior that engages thethreads on the exterior of the tube. The distal ends of the foldingmembers are connected to a ring that is not internally threaded. Thisring allows the tube to rotate therein, but (because it is notinternally threaded) does not cause the ring to ride up the threads ofthe tube. The opposite ends of the folding members are connected to theflange.

With this configuration, when the tube is rotated (preferably byengagement with the handset or with a surgeon's fingers), the threadedengagement of the exterior of the tube with the interior of the flangecauses the tube to move outwardly (with respect to the interior of apatient's body). This action causes the folding members to fold at thecrease. In use with a patient, in the folded position, the proximal endof the tube is located outside of the patient's body, and the distal endhas moved closer to the flange than it was in the unfolded position.

With reference to FIGS. 18-20, a knot positioning implement 140 is shownand described. After both ends 150 a and 150 b of the suture 150 arethreaded and the support matrix 200 has been created, the two sutureends 150 a and 150 b are brought out through the midline sub-mentalaccess site (through port 120), as is shown in FIG. 19. A single throwknot 150 c is placed (it will be understood that the type of knot is nota limitation on the present invention) and the knot positioningimplement 140 is utilized to set the knot 150 c.

One end 142 of the knot positioning implement 140 (which is preferablythreaded) docks with the handset 60 and the other end 144 is forked. Theforked end 144 is used to push the knot 150 c through the tunnel 128 ofthreaded skin port 120 and under the skin. In a preferred embodiment,the knot positioning implement 140 includes a fiber optic core 152 andan opening 152 a through which light is transmitted to illuminate thework area when placing the knot 150 c.

After the knot 150 c has been pushed through the threaded port 120,threaded port 120 is twisted out of the access site and the other skinports 80 are removed using the handset 60. To do this, the maleconnector 68 is inserted into the port 80 so that the ridge 68 a snapsinto the indented ring 82 a and the teeth 68 b and 82 b engage oneanother. The handset 60 is then twisted, thereby turning tube 84 andcausing the internally threaded ring 90 b to travel back down threads 88and unfolding folding the folding members 90 a. In another embodiment,the ports 80 can be removed by hand.

After atraumatic removal of the ports 80 and 120, steristrips are thenplaced as desired and a neck compression garment is fitted onto thepatient. See FIG. 25 for the final configuration of the exemplarysupport matrix 200.

In a preferred embodiment, the suture that is used in the procedure is a4.0 braided polyester suture. In a more preferred embodiment, as shownin FIG. 24, the suture design contains at least one fiberoptic strand150 d intertwined with the non-fiberoptic strands. The suture 150 isbraided as is known in the art with one, two or three fiberoptic strandsand one or two non-fiberoptic strands, as is desired. This aids in thetransillumination of the suture 150 to check subcutaneous placementafter the suture 150 has been placed. The fiberoptic strand 150 d willilluminate when the handset 60 fiberoptic light coupled with the knotplacement implement 140 is approximated to the suture during tying.Light transmitted to the suture allows the surgeon to visualizeplacement of the support matrix 200 as it is secured. The non-fiberopticstrands can be made of any material known in the art, such as nylon,polypropylene, or other non-absorbable material.

At any point during the creation of the support matrix 200, sutureplacement can be confirmed by placing the handset 60 (or any lightsource) at one of the ends 150 a or 150 b of the suture 150, therebytransmitting light down the fiberoptic strand 150 d to check placementof the suture 150.

The illumination of the suture pathway allows the surgeon to determinethe location of the suture. Overall, suture illumination gives thesurgeon feedback relating to the anatomical movement of each pivotpoint.

It will be appreciated by those skilled in the art that the fiberopticsuture can be utilized in all areas of surgery or other materials wherea lit binding material is needed, and not just in the techniquedescribed herein. In another embodiment, the threading device may be astraight or curved needle. Application of light energy during a surgicalprocedure will confirm suture placement and accuracy. Application oflight post-operatively could allow surgeons to understand the evolutionof suture placement related to time and aging.

In an alternative embodiment, the neck skin can be elevated from theplatysma muscle via an incision similar to that used in the standardprocedure discussed above to allow the surgeon to visualize theoperative field and then the suture matrix can be placed through theports 80 and access sites 14.

It is contemplated that the above described instruments can be sold inkits. For example, a kit with all or any combination of the instruments,including the tape 10, a marking pen, lancet 40, handset 60, skin ports80, threading device 100, threaded skin port 120, knot positioningimplement 140 and suture 150 can be sold.

The embodiments described above are exemplary embodiments of the presentinvention. Those skilled in the art may now make numerous uses of, anddepartures from, the above-described embodiments without departing fromthe inventive concepts disclosed herein. Accordingly, the presentinvention is to be defined solely by the scope of the following claims.

1. A knot positioning implement comprising a. an elongated tube havingan interior and first and second opposite ends each having an openingtherein, wherein the first end of the elongated tube is forked andwherein the second end includes a threaded connector, and b. afiberoptic core comprising at least one fiberoptic strand extendingthrough the interior of the elongated tube, whereby light is transmittedthrough the opening in the first end of the elongated tube when the atleast one fiberoptic strand is energized.
 2. The threading device ofclaim 1 wherein the threaded connector comprises external threads on theelongated tube.
 3. The threading device of claim 2, wherein theelongated tube is made of metal.
 4. The threading device of claim 3wherein the fiberoptic core includes a plurality of fiberoptic strands.5. A method of positioning a suture knot under the skin of a person, themethod comprising the steps of: a. providing a knot positioningimplement comprising an elongated tube having an interior and first andsecond opposite ends each having an opening therein, wherein the firstend of the elongated tube is forked, thereby defining a recess, andwherein the second end includes a threaded connector, b. pulling twoends of a suture through an opening in the skin, c. tying the two endsof the suture into a knot, d. placing the knot into the recess in theforked end of the knot positioning implement, and e. pushing the knotthrough the opening in the skin using the knot positioning implement. 6.The method of claim 5 wherein the knot positioning implement includes afiberoptic core comprising at least one fiberoptic strand extendingthrough the interior of the elongated tube, whereby light is transmittedthrough the opening in the first end of the elongated tube when the atleast one fiberoptic strand is energized.
 7. The method of claim 6wherein the opening in the skin includes a skin port inserted thereinthrough which the knot positioning implement and knot are inserted. 8.The method of claim 5 wherein the knot positioning implement isconnected to a handset before step (d).
 9. The method of claim 5 whereinthe knot positioning implement is connected to a handset before step(d), and wherein the handset includes a fiberoptic core that illuminatesthe fiberoptic core of the knot positioning implement.